Healthcare Provider Details

I. General information

NPI: 1093647232
Provider Name (Legal Business Name): YONGSEONG KIM PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2679 WAYWARD CT
BREA CA
92821-4665
US

IV. Provider business mailing address

2679 WAYWARD CT
BREA CA
92821-4665
US

V. Phone/Fax

Practice location:
  • Phone: 951-323-6958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT310169
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: